Tuesday, October 28, 2008

Twilight Zone

"O, let me not be mad, not mad, sweet heaven,
Keep me in temper: I would not be mad."

King Lear

When a patient says, spontaneously and early in an interview, "I am not delusional," it could be either a good or a bad sign, prognostically, but it does portend an interesting session. Patients with schizophrenia or bipolar disorder are often in denial, but not typically in such an explicit and articulate fashion. Delusional Disorder is something of an oddity, a diagnostic stepchild. Patients suffering from it often have well-preserved cognitive and behavioral function, such that they are less likely to come to clinical attention than other psychotic patients. Age of onset is somewhat later, often middle age, and in my experience at least, women are more commonly affected.

In many cases of psychotic disorder the pathology hits you in the face, figuratively speaking; the question is primarily how to manage it, how to try to rebuild. If schizophrenia is a half-demolished city block, then delusional disorder is an outwardly unremarkable one: a little faded, perhaps, and somewhat deserted, but seemingly intact. Then suddenly you walk around a corner and nearly fall into a gaping sinkhole; picking up a volume of Thomas Mann, you open it and instead find a Kafka story. Or maybe it's more like stepping into an Escher print--no matter how far you seem to walk, you always end up where you started.

I find it uncanny at times to be with patients like this. It is as if our respective realities only partially overlap; the person seems only halfway within "my" usual epistemological universe. We witness the same states of affairs, in a literal sense, but we make totally different inferences from them. With other psychotic patients I don't really get this sensation. They may hear voices or they may think they're Jesus Christ, but they're either with me or they're not (in a metaphysical, not a moral, sense); patients with delusional disorder are half with me, half not, sort of like the Nazgul in Middle Earth (but without sinister implication). Maybe it's a bit like confronting a hologram--it seems like you could just reach out and connect, but you miss every time.

I thought of this for some reason the other day when I read a fascinating, and inexpressibly sad, profile (encountered by way of Arts and Letters Daily) of a family who perished in the Jonestown mass suicide in Guyana. If loving parents cannot get through to an only daughter in the grip of delusion, then who could? Fanaticism of all stripes as well as cult behavior provokes the same experience with me, the disconcerting feeling that some people may be physically next door but, in another sense, inhabiting parallel, and shocking, universes.


Anonymous said...

This one is a rather interesting post. I never really thought about it as a diagnosis, but you do get a lot of older people who have some fixed delusion (or idee fixed - is that sort of the term when it's slightly lighter and more malleable than a full on delusion?) who don't have other outward signs of a psych disorder. Even a lot of times it improves when their physical ailments improve. It is strange. You can talk to them about anything, and they are perfectly normal, but you hit that one thing about the son in law out to get them, or the tumor they are sure they have that the doctors keep lying about, no matter what workup has been done, and there's no discussion. Never called it "delusional disorder" before, but I guess that's what it is.

Novalis said...

There's an antique term, paraphrenia, that used to be used for this kind of circumcribed delusion in late life, but it isn't in the DSM and has generally been incorporated into diagnoses of schizophrenia or delusional disorder.

Technically, DSM-wise, one cannot diagnose schizophrenia based on delusions alone (i.e. in the absence of hallucinations or disorganized speech or behavior) unless the delusions are "bizarre." Of course, non-psychotic observers can reasonably differ on what constitutes "bizarre."

Anonymous said...

Do mild delusions necessarily progress to full-blown socially unacceptable delusions if left untreated? Or can these small disparities be considered as personality quirks and be allowed to happily live inside an otherwise 'normal' person without major ill-effect?

By mild I mean a belief that elicits the occasional raised eyebrow; that doesn't quite conform to anyone else's reality but is so inconsequential that you can let it be because in the end, it only amounts to the micro-difference between two shades of red.

Anonymous said...

I know of someone who has only one peculiar belief (I guess it would qualify as a delusion, maybe not), which is that people taking antidepressants unintentionally cause Cushing's syndrome in their close associates by some form of telepathy. No amount of reasoning can shake her from this belief, yet in all other respects she seems "normal" (whatever that means), and is able to function independently. Does that qualify as a delusion? How common is it for someone to have only one (known) delusional belief?

Novalis said...

The idea of delusion is a fascinating one, particularly as psychology increasingly shows that none of us is as rational as we sometimes like to believe.

One could look at irrational beliefs as existing on a continuum from the common, quirky, and relatively harmless (e.g. belief in ghosts) to the more idiosyncratic and worrisome such as clear paranoia. But some are hard to categorize.

Consider the belief some hold that neither the 1969 moon landing nor the 9/11 attacks actually happened, but were rather staged for media consumption (the belief that 9/11 happened but was orchestrated by the U.S. or Israel is a variant on this). In most people's views these are pretty "wacko" beliefs, but no one could (should) be diagnosed as psychotic merely for this belief because it exists as part of a peculiar subculture of belief. Analogous beliefs might be firm conviction about UFO's or alien abduction.

Another way of looking at it is: if one person holds a fixed false belief, it is a delusion; if a few dozen hold it, it is a cult; if a few million hold it, it is a religion. I don't personally hold the latter, although some like Richard Dawkins ("The God Delusion") obviously do. In fact, I would argue that the whole terrain of mental disorder is ultimately decided by social consensus, so delusions are too.

Some people seem to view psychiatric diagnosis as not only not scientific, but also imposed on humanity by some cabal of shrinks or scientists behind closed doors. Nothing could be further from the truth; it may not be as scientific as we would like, but it is democratic, and driven by grass-roots pressures in the form of social expectation.

Anonymous said...

If we approach the idea of delusion as a mathematical problem -- a mental system that has quantifiable features that can be pitted against each other to determine the balance of positive vs negative effect in the individual and the greater social circle he/she influences -- might we be closer to a more democratic solution to the problem of what beliefs qualify as deranged/acceptable?

But then you encounter the problem of assigning a numerical value to a positive or negative effect which is mostly arbitrary and subjective.

After all, my idea of positive effect might be completely off the scale of what turns out to be your negative effect spectrum and thus, we will never meet in a comfortable shade of grey of the same scale.

I mean, how many cockroaches does it take to cause an infestation: when you find one critter in your bed or two? We'll always end up splitting hairs when it comes to classification of delusions.

Is having a delusion equal to being delusional? I think not; there's a tipping point when the sum of your 'delusions' is greater than the sum of every other psychological aspect that qualifies as making you a 'unique' person in the mental range.

...Which feeds back into the indeterminate nature of delusion profiling.

We will never win. It's a crime scene. I'll believe my delusions and you yours and sometimes they'll meet and we'll call it a fact.

Unknown said...

Ahhhhh! I accidentally closed the window and my entire comment disappeared.

Here's a briefer version:

Anon 926, Have you ever seen the Discovery Channel show "Most Evil," with Dr. Michael Stone? Dr. Stone is a forensic psychiatrist who tries to quantify "evil" in a categorically structured way. His conclusions seems a bit arbitrary to me, although the degree of sociopathy does seem to escalate in a relatively straightforward way.

Here's the Wiki page (I hate Wiki) that details the entire scale:


(the first post had a hot link, but opened the page in the tiny comments window)

I agree with your concern about subjectivity being an issue when trying to create a mathematical formula, and would add other confounding factors may be co-existing Axis I and II disorders, Current GAF, type and uniqueness of content, and lots of other things I'm not aware of.

Novalis? Anyone else?

BTW, Novalis, you're living in my Home State. I hope you're taking good care of it in my absence. :)

Novalis said...

As I see it psychiatric diagnosis is so vexing because, unlike every other specialty, it deals with the health or illness of the self rather than a particular body part. Various organs and systems--liver, skin, bone, what have you--have unambiguous functions in keeping the organism alive and functional.

Neurologists deal with the brain insofar as it mediates movement, sensation, speech, etc. but psychiatrists deal with the brain insofar as it generates a self. The trillion dollar philosophical question is: what is a self "for," what is its function? We have to agree on this question to decide when a self is impaired.

Drawing on evolutionary theory, some have argued that survival and reproduction are the ultimate parameters of an organism's wellness, but arguably society doesn't consciously view it that way any more. What makes life admirable or worth living can be endlessly contested, but most would object to a narrowly evolutionary view. Someone who lives to be 90 and has 30 grandchildren is not intrinsically more "healthy" or worthwhile than someone who dies childless in his 20's (Keats, Schubert, etc.).

I guess I've come around to the view that the health of a self does not reside in any particular content, but rather in open-endedness itself, the freedom to modify and determine its range of expression and relatedness. So a self is impaired inasmuch as its emotional, behavioral, and relational repertoire is restricted relative to the human average. However, this is likely informed by my context in the individualistic West, and one can easily envision other societies, other contexts of social consensus, that may arrive at a rather different view.

Anonymous said...

Thanks Marcia. I haven't heard of 'Most Evil', but I'm most intrigued! My favourite category is 9: love turns us all into psychopaths...it's a matter of degrees.

Novalis, it is all about statistical averages isn't it? Even a society of psychopaths has a mean 'sane' range; and any psycho that dares to fall too close to the right on the scale, will burn..in heaven!

Each to their own...